Changes in energy and macronutrient intakes during Ramadan fasting: a systematic review, meta-analysis, and meta-regression

CONTEXT

Ramadan fasting (RF) is associated with various physiological and metabolic changes among fasting Muslims. However, it remains unclear whether these effects are attributable to changes in meal timing or changes in dietary energy and macronutrient intakes. Furthermore, the literature on the associations between RF, meal timing, and energy and macronutrient intakes is inconclusive.

OBJECTIVES

This systematic review aimed to estimate the effect sizes of RF on energy and macronutrient intakes (carbohydrates, protein, fats, dietary fiber, and water) and determine the effect of different moderators on the examined outcomes.

DATA SOURCES

The Cochrane, CINAHL, EMBASE, EBSCOhost, Google Scholar, PubMed/MEDLINE, ProQuest Medical, Scopus, ScienceDirect, and Web of Science databases were searched from inception to January 31, 2022.

DATA EXTRACTION

The studies that assessed energy, carbohydrate, protein, fat, fiber, and water intakes pre- and post-fasting were extracted.

DATA ANALYSIS

Of the 4776 identified studies, 85 relevant studies (n = 4594 participants aged 9-85 y) were selected. The effect sizes for the studied variables were as follows: energy (number of studies [K] = 80, n = 3343 participants; mean difference [MD]: -142.45; 95% confidence interval [CI]: -215.19, -69.71), carbohydrates (K = 75, n = 3111; MD: -23.90; 95% CI: -36.42, -11.38), protein (K = 74, n = 3108; MD: -4.21; 95% CI: -7.34, -1.07), fats (K = 73, n = 3058; MD: -2.03; 95% CI: -5.73, 1.67), fiber (K = 16, n = 1198; MD: 0.47; 95% CI: -1.44, 2.39), and water (K = 17, n = 772; MD: -350.80; 95% CI: -618.09, 83.50). Subgroup analyses showed age significantly moderated the 6 dietary outcomes, and physical activity significantly moderated water intake. There were significant reductions in energy, carbohydrate, and protein intakes during RF.

CONCLUSIONS

The change in meal timing rather than quantitative dietary intake may explain various physiological and health effects associated with RF.

LecturePlus: a learner-centered teaching method to promote deep learning

A new teaching format, the LecturePlus, was formulated as a lecture followed by small-group learning activities. This study assessed the effectiveness of LecturePlus in medical education. An interventional study was conducted among final-year medical students, with 74 students in the experimental group and 96 students in the control group. Each LecturePlus lasted ∼1 h and was conducted with 12-18 students. A LecturePlus session comprised of a lecture followed by small-group problem-solving exercises. The exercises were clinical cases with open-ended short-answer questions. Students were divided into groups of three (triads) for these exercises. A faculty tutor assisted the small groups as needed. Closure was achieved through a discussion moderated by the tutor. Learning outcomes were assessed via the National Board of Medical Examiners (NBME) subject scores and compared with those of the preceding academic year. An additional multiple-choice question (MCQ) test was administered before and after the clerkship. The MCQ test showed improvement in knowledge application (P < 0.001, partial eta squared = 0.42). There was a statistically significant improvement in adjusted NBME scores among female students (74.8 vs. 71.8; P = 0.017) but not among male students. An anonymous written questionnaire survey showed high ratings for LecturePlus (95% selecting yes or partly yes to overall satisfaction). LecturePlus is an instructional strategy that integrates a lecture with learning activities. It can be scaled to large class sizes facilitated by one teacher. By combining didactic teaching with problem-solving, this new instructional strategy may foster application of knowledge.NEW & NOTEWORTHY We developed a new structured teaching format, the LecturePlus, to promote deep learning. A LecturePlus session consists of a brief lecture, followed by small-group problem-solving exercises, ending with a closing discussion moderated by the teacher. During the small-group exercises, students were divided into groups of three (triads) and given case-based problems. One faculty tutor supervised the entire session. LecturePlus resulted in improved learning outcomes and was rated highly by medical students.

Examination of sleep in relation to dietary and lifestyle behaviors during Ramadan: A multi-national study using structural equation modeling among 24,500 adults amid COVID-19

Background

Of around 2 billion Muslims worldwide, approximately 1.5 billion observe Ramadan fasting (RF) month. Those that observe RF have diverse cultural, ethnic, social, and economic backgrounds and are distributed over a wide geographical area. Sleep is known to be significantly altered during the month of Ramadan, which has a profound impact on human health. Moreover, sleep is closely connected to dietary and lifestyle behaviors.

Methods

This cross-sectional study collected data using a structured, self-administered electronic questionnaire that was translated into 13 languages and disseminated to Muslim populations across 27 countries. The questionnaire assessed dietary and lifestyle factors as independent variables, and three sleep parameters (quality, duration, and disturbance) as dependent variables. We performed structural equation modeling (SEM) to examine how dietary and lifestyle factors affected these sleep parameters.

Results

In total, 24,541 adults were enrolled in this study. SEM analysis revealed that during RF, optimum sleep duration (7-9 h) was significantly associated with sufficient physical activity (PA) and consuming plant-based proteins. In addition, smoking was significantly associated with greater sleep disturbance and lower sleep quality. Participants that consumed vegetables, fruits, dates, and plant-based proteins reported better sleep quality. Infrequent consumption of delivered food and infrequent screen time were also associated with better sleep quality. Conflicting results were found regarding the impact of dining at home versus dining out on the three sleep parameters.

Conclusion

Increasing the intake of fruits, vegetables, and plant-based proteins are important factors that could help improve healthy sleep for those observing RF. In addition, regular PA and avoiding smoking may contribute to improving sleep during RF.

Management of Blunt Sternal Fractures in a Community-Based Hospital

Background

Sternal fractures are not commonly observed in patients with blunt trauma. The routine use of computed tomography (CT) in the evaluation of chest trauma helps identify these fractures. We studied the incidence, injury mechanism, management, and outcome of sternal fractures in patients with blunt trauma treated at our community-based hospital.

Methods

We retrospectively reviewed the chest CT scans of all patients with blunt trauma who were presented to our community-based hospital from October 2010 to March 2019. The study variables included age at the time of injury, sex, mechanism of injury, type, and site of fracture, associated injuries, Glasgow Coma Scale, Injury Severity Score, need for intensive care unit admission, hospital stay, and long-term outcome.

Results

In total, 5632 patients with blunt trauma presented to our hospital during the study period, and chest CT scan was performed for 2578 patients. Sternal fractures were diagnosed in 63 patients. The primary mechanism of injury was a motor vehicle collision. The most common site of fracture was the body of the sternum (47 patients; 74.6%). Twenty (31.7%) patients had an isolated sternal fracture with no other injuries. Seven (11.1%) patients were discharged directly from the emergency department. Two patients died (overall mortality rate, 3.2%) and two experienced long-term disability.

Conclusions

The incidence of sternal fractures in our patient population was similar to that reported by tertiary hospitals. Patients with a sternal fracture and normal cardiac enzyme levels and electrocardiogram may be safely discharged from the emergency department, provided there are no other major injuries.

Digital interventions for smoking abstinence: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Technological advancements have improved patients' health and clinical care through digital interventions. This study investigated the effects of digital interventions on smoking abstinence.

METHODS

PubMed, the Cochrane Library, and Scopus were systematically searched from inception until December 2021. Meta-analysis was carried out using a random-effects model. The degree of heterogeneity, quality, and publication bias of the selected studies was further evaluated.

RESULTS

A total of 43 randomized control trial studies were eligible for this study. 38,814 participants from 18 countries were included in the analysis. Digital interventions on seven-day point prevalence abstinence (1 month) showed increased smoking abstinence. The odds ratio was 2.02 and confidence interval (CI) was 1.67-2.43; p < 0.001; I² = 55.1%) . The result for a 30-day point prevalence abstinence (1 month) was 1.63 (CI 1.09-2.46; p = 0.018; I² = 0%). Digital intervention also had a significant effect on continuous abstinence (odds ratio = 1.68; CI 1.29-2.18; p < 0.001; I² = 70.1%) and prolonged abstinence (odds ratio = 1.60; CI 1.19-2.15; p = 0.002; I² = 53.6%). There was evidence of heterogeneity and publication bias.

CONCLUSIONS

Digital interventions led to increased smoking abstinence and can be a valuable tool in smoking cessation. Further research is required to evaluate the long-term impact of digital interventions on outcomes related to smoking cessation.

Elevated troponin level and nonspecific ST‐segment and T‐wave changes in a suspected acute pancreatitis patient, post‐SARS‐Cov‐2 infection: A case report

The case report describes a post‐COVID‐19 patient with severe right upper quadrant (RUQ) pain, moderate epigastric pain, high troponin levels, and nonspecific ST‐segment and T‐wave changes on electrocardiogram (ECG).

The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study

BACKGROUND

Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries.

METHODS

We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year.

RESULTS

In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019.

CONCLUSIONS

Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

Complementary feeding practices and the associated risk of childhood obesity among ethnic minority groups living in high-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Complementary feeding (CF) is defined as the period from when exclusive breast milk and formula are no longer sufficient for meeting the infant's nutritional needs. The CF period occurs from birth to 23 months of age. Though the recommended guidelines for introducing CF is from around 6 months of age, data indicates that some infants are introduced to food earlier than 6 months which can predispose children to obesity and overweight. Obesity in ethnic minority groups (EMG) is higher than their native counterparts and often tracks into adulthood. Hence, our aim was to conduct a systematic review and meta-analysis on the available literature to identify the risk of childhood overweight/obesity associated with CF practices concerning their timing, as well as the frequency and type of CF food introduced. We focused specifically on EMG children living in high-income countries.

METHODS AND ANALYSIS

A methodological literature search surrounding childhood obesity and overweight (COO) risk associated with CF practices will be conducted in May 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. The following academic databases will be methodologically searched: PubMed, EMBASE, PsycINFO, CINAHL, SCOPUS, Cochrane Library and the WHO Global Index Medicus. Three independent researchers will be involved in independent screening and review the included articles based on the predefined inclusion and exclusion criteria. Where conflicts arise during the screening process, it will be resolved through discourse until a consensus is reached. Information on CF practices and anthropometric measurements will be extracted to ascertain the risk of COO. For this study, WHO body mass index for age and sex percentiles, Centers for Disease Control and Prevention classification and other recognised country-specific classifications will be utilised for the outcome.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed as the results will be drawn from currently available published literature. Outcomes of the review will be shared through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021246029.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).

Medication Adherence Among Patients with Multimorbidity in the United Arab Emirates

BACKGROUND

Multimorbidity, defined as having two or more chronic diseases, has a major impact on public health and Sustainable Development Goals (SDG). This study aims to assess the prevalence of medication adherence and associated factors among patients with multimorbidity.

METHODS

A questionnaire-based, cross-sectional survey was conducted by a trained interviewer across patients with multimorbidity attending outpatient clinics in two tertiary referral hospitals in the United Arab Emirates (UAE). Demographic and social variables and the outcome (self-reported adherence to long-term medication) were measured using the General Medication Adherence Scale (GMAS). Multiple logistic regression was used to assess medication adherence and associated factors.

RESULTS

From a total of 630 participants included in this study, the estimated prevalence of high medication adherence is 78.57% (±1.63478) with a 95% confidence interval (CI) [75.19, 81.61]. The odds of high medication adherence increased with age. The odds of high medication adherence for patients aged 66 years and older than those aged 19-35 years is adjusted odds ratio (AOR) = 3.880, with a 95% CI [1.124, 13.390]. Patients with income more than 50,000 had the odds, AOR = 5.169 with a 95% CI [1.282, 20.843], compared to those earning less than 10,000 Dirhams (AED). Patients aged 36-65 with health insurance coverage had higher medication adherence than groups on the other end. The number of current medications is significantly (p-value = 0.027) associated with high medication adherence with the odds of high medication adherence, AOR = 4.529 with a 95% CI [1.184, 17.326], the highest for those currently taking four medications.

CONCLUSION

This study highlights younger population having multimorbidity in the context of an increasing life expectancy and suboptimal therapeutic outcomes. Furthermore, the study highlights multimorbidity is associated with low medication adherence and out-of-pocket payment, and non-availability of insurance is a major hindrance to medication adherence.

A Rare Case of an Intra-nasal Ectopic Tooth in a Young Woman

Teeth in non-dentate areas including the intra-sinus and intranasal teeth are rarely encountered in clinical practice. Although the majority of patients remain asymptomatic, the usual presenting complaints are nasal obstruction, epistaxis, hyposmia and headache. In this article, we present a case of an intranasal tooth in a 15-year-old female who presented with complaints of hyposmia and nasal obstruction. Computed tomography (CT) of the paranasal sinuses and nasal cavity showed a tooth-like structure in the left inferior nasal cavity extending from the hard palate. The mainstay of treatment is the surgical removal of the ectopic tooth under anaesthesia. Even in asymptomatic patients, surgical removal of the nasal tooth is advised to prevent complications. Along with a clinician’s understanding of the condition, imaging aids in the diagnosis of an ectopic tooth. Imaging, particularly with CT, also helps plan the surgical approach to treatment.

Hepatic hydatid cyst presenting as a cutaneous fistula

Hepatic hydatid cysts are usually asymptomatic. Nevertheless, they may rupture, causing anaphylactic shock or fistulation. Cutaneous fistulae caused by ruptured hepatic hydatid cysts are extremely rare. Herein, we report a case of infected cutaneous fistula caused by a ruptured hepatic hydatid cyst. A 57-year-old man presented to Al-Ain Hospital complaining of swelling in his right upper quadrant (RUQ) of 5 months' duration. The abdomen was soft, having a fluctuant tender swelling of 12 cm × 15 cm in the RUQ associated with a pus discharging fistula. The patient was admitted with a provisional diagnosis of abdominal wall abscess with pending sepsis. Surgical incision and drainage were performed under general anesthesia. Initially, around 15 ml of pus was drained, followed by the removal of multiple sized transparent cysts typical of hydatid disease. Postoperative abdominal computed tomography (CT) scan showed multiloculated hepatic cysts in the sixth, seventh, and left lobes with the involvement of the abdominal wall. The patient was treated with oral albendazole 400 mg twice daily for 30 days. Repeated CT scan at 4-month follow-up showed a significant reduction of size of the cysts, indicating proper response to treatment. A cutaneous fistula as a complication of a ruptured hepatic hydatid cyst is extremely rare. Awareness of this complication, especially in endemic areas, and using proper imaging and serological tests are vital for reaching a proper diagnosis.

Point-of-care ultrasound for the acute abdomen in the primary health care

Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.

Eosinophilic colitis

Eosinophilic colitis is a rare chronic inflammatory bowel condition of unknown etiology. We report a case of cecal volvulus causing obstruction in a patient with eosinophilic colitis. A 48-year-old lady presented with abdominal pain, constipation, and abdominal distension. Clinically and radiologically, she was diagnosed to have cecal volvulus. Preoperative colonoscopic reduction failed. At laparotomy, a right hemicolectomy with primary anastomosis was undertaken. Histology of the resected specimen showed diffuse eosinophilic infiltration suggesting eosinophilic colitis. To the best of our knowledge, this association has been never reported.

Reidel’s thyroiditis and Tolosa-Hunt syndrome, a rare association

A previously undescribed association of Reidel’s thyroiditis with Tolosa-Hunt syndrome is reported. A 33 year-old Caucasian female presented with a two-year historyof painful progressive goitre, histologically a Reidel’s thyroiditis. She underwent left partial thyroidectomy. Post-operatively she developed severe right retro-orbital pain, right temporal headache and a partial right occulomotor nerve palsy. A diagnosis of Tolosa-Hunt syndrome was made. Some important aspects of this case are discussed.